Educational activism for planetary health—a case example from The Netherlands
Authors: Juliette C Mattijsen, Egid M van Bree, Evelyn A Brakema, Maud M T E Huynen, Eva H Visser, Peter J Blankestijn, Philip N D Elders, Hans C Ossebaard
Journal: The Lancet Planetary Health (2023)

This Comment presents a case example of Dutch educational activism in response to growing concerns about our planet's health. After briefly outlining the relevant Dutch context, we describe the GREENER-collective, hoping to inspire others to organise educational activism to advance planetary health. GREENER stands for green health-care education for a healthy future. With an annual turnover of €100 billion and employing 14% of the working population, the Dutch health-care sector is of major economic value. The sector produces 7% of the country's greenhouse gas emission, produces 4% of its total waste, and contributes 13% to raw material use.1Steenmeijer MA Rodrigues JFD Zijp MC Waaijers-van der Loop SL The environmental impact of the Dutch health-care sector beyond climate change: an input–output analysis.Lancet Planet Health. 2022; 6: e949-e957Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar Since 2015, a small programme, run by the ministry of Health, has promoted sustainability in health care. Its main output was the Green Deal, a collaborative policy instrument. In the Green Deal (version 2.0), over 300 health care-related parties pledged to strive for environmental sustainability within their respective missions. So far, this pledge has not led to large-scale adaptations in health care. The voluntary and non-binding agreement did not involve sanctions or rewards. General urgency awareness is poor and fragmented, policy objectives are soft, and a clear oversight of effective interventions is missing. In November 2022, a successive Green Deal (version 3.0) was established (panel). Although more ambitious, the Green Deal is still voluntary in nature and lacks substantial funding. The stakeholders' arena is focused on post-COVID-19 recovery, waiting lists, serious understaffing, and budgetary cuts. However, the Green Deal 3.0's second objective is hopeful as it explicitly involves integrating sustainable care and planetary health in health education. This integration was accomplished by health professionals' activism.PanelGreen Deal 3·0 (2022–26) objectives for the Dutch health-care sector1.More focus on promoting health for patients, clients and professionals, and the population2.Promoting awareness and knowledge about the environment–health–health care relationship3.Reducing carbon emissions of the total health-care sector emission by 55% in 2030 (climate neutrality in 2050)4.Reducing raw material use in the sector to 50% by 2030 (maximal in 2050)5.Reducing medication-related pollution 1.More focus on promoting health for patients, clients and professionals, and the population2.Promoting awareness and knowledge about the environment–health–health care relationship3.Reducing carbon emissions of the total health-care sector emission by 55% in 2030 (climate neutrality in 2050)4.Reducing raw material use in the sector to 50% by 2030 (maximal in 2050)5.Reducing medication-related pollution After decades of relative indifference, green momentum is increasing among predominantly young health-care students and professionals in the Netherlands. They observe the contribution of their health-care services to the ecological crises and the lack of institutional and political response. Scientific evidence supports their concerns and inspires many to act—eg, by participating in the climate protests and strikes. The Dutch Organization for Health Research and Development published a knowledge agenda on climate change and health.2Huynen M Knowledge agenda on climate change and health. ZonMw.https://www.zonmw.nl/fileadmin/zonmw/documenten/Gezondheidsbescherming/Kennisagenda_Klimaat_en_Gezondheid_digi_versie.pdfDate accessed: November 3, 2022Google Scholar The agenda called for an urgent integration of climate change into health-related education programmes. Bottom-up projects have rapidly emerged since 2019, involving health-care professionals, teachers, and students. However, top-down, educational institutions have hardly progressed on climate change. Students and medical residents have started organising planetary health webinars, attracting large audiences. A manifesto of physicians for a healthy earth, signed by over 1000 health-care professionals, urged for climate action and integration of the topic in medical education.3Manifest-van-medici voor een gezonde aarde.https://milieuplatformzorg.nl/manifest-van-medici/Date accessed: December 15, 2022Google Scholar Green health-care committees and green teams have emerged from within varying health disciplines. Within just 1·5 year, over 100 grassroot organisations have united in the Dutch Green Health Alliance (Groene Zorg Alliantie), which rapidly integrated into the Dutch health infrastructure. Collaboratively, they pleaded for planetary health in education. In 2020, the Dutch Minister of Health officially acknowledged the importance of environmental sustainability in health-care education.4Dutch Ministry of HealthLetter to the Parliament 1710954–207430-PDZ (07–07–2020). Ministry of Health, The Hague2020Google Scholar Among other examples, a parliamentary letter stated the need for a study to clarify the current educational attention paid to the health effects of climate change and pollution, the impact of health care on climate and environment, and the options for a more sustainable health-care delivery. This parliamentary letter opened an actionable space. Part of this thriving momentum was the GREENER collective, formed in November, 2020, after a virtual network meeting about research in climate and health. GREENER is a diverse, multidisciplinary group of medical students, health professionals, scientists, and policy advisors across the country, each with relevant experiences and networks. The informal expert group calls for quick and immediate innovation of health curricula to educate students and young professionals on planetary health themes.5Van Bree EM Mattijsen JC Call to integrate climate change in medical education.Ned Tijdschr Geneeskd. 2022; 166D6455PubMed Google Scholar Their shared mission is to offer every (future) health-care professional knowledge and skills in planetary health and sustainable, resilient health-care delivery. This mission includes advocacy and research to effectively integrate planetary health into existing curricula. GREENER has achieved meaningful outcomes since and we have identified several factors to explain this success. GREENER features passionate commitment, diversity, and a non-hierarchical structure. It grew from personal and professional concern about the global ecological crisis and its implications for human health and societies across the planet. This high and effective commitment proved to be one of the driving forces for the bottom-up emergence of an ongoing collaboration. The decentralised nature enabled flexibility to rapidly connect to other networks and formal actors at all levels, and to act on gaps and opportunities in current health-care education across the country. This flexibility to rapidly connect to other networks resulted, for example, in an innovative project initiated by GREENER in collaboration with the Dutch General Practitioner Vocational Training to embed planetary health in their curriculum. The Ministry of Health granted GREENER, in collaboration with the Leiden University Medical Center, funding to assess the presence of planetary health and sustainable health care in health programmes at Dutch universities.6Visser EH Wiggers LMC Brakema EA Inventarisatie duurzaamheid in universitaire opleidingen in de gezondheidszorg. Assessing the presence of sustainability in university health and healthcare curricula.https://greenermedischonderwijs.wordpress.com/rapport-inventarisatie-2022/Date accessed: June 15, 2022Google Scholar GREENER found that planetary health was hardly present and developed an agenda specifying each stakeholder's roles and tasks to change this absence (figure). GREENER organised the first Dutch conference catalysing planetary health in education. The conference attracted more than 100 students, lecturers, health professionals, and educational directors. It provided the necessary imagination and basic planetary health knowledge, an update on the educational state of affairs, and practical workshops to address knowledge gaps, implementation barriers, and facilitators. The second edition (2022) was an even bigger success proving that many lecturers feel the need to cooperate, exchange, and develop knowledge on planetary health education. GREENER also developed a roadmap detailing, step-by-step, how to integrate planetary health in Dutch university health-care education.7Van Bree E Mattijsen JC Warmerdam LA De Ridder EF Planetary health: ter bescherming van de menselijke gezondheid en de planeet. Een handreiking voor onderwijsimplementatie in universitaire zorgopleidingen. Planetary Health: to safeguard human health and the planet. A guideline for educational implementation in university healthcare curricula.https://www.rijksoverheid.nl/binaries/rijksoverheid/documenten/rapporten/2022/05/22/planetary-health-een-handreiking-voor-onderwijsimplementatie-in-universitaire-zorgopleidingen/handreiking-planetary-health.pdfDate accessed: November 11, 2022Google Scholar We now seek to include post-secondary vocational training as product of GREENER. If the health-care sector is to greenify, the full width of the professional spectrum must be engaged. Too many promises have taken too long to materialise in the face of the global planetary emergency. From successfully pleading for the Netherlands to sign the WHO commitment for climate-resilient and climate-friendly health systems during COP26 via the Dutch Green Health Alliance to coorganising the largest health-care mobilisation at the Dutch Climate march in November, 2021, GREENER advocates for political and institutional change. Visible and invisible activism fosters a sense of community and belonging. It strengthens collective ideals, sparks joy, and strengthens the Dutch Climate and Health movement. Education is a powerful tool to integrate science with civic and academic responsibility, to inspire, and to, ultimately, change the world. The planetary health paradigm provides key arguments that contribute to building the climate justice movement, to accelerating systems change, and to advocating for more resilient and fairer societies. Transformative coalitions start from the heart and move via the intellectual and creative domains towards action. They are dedicated, multidisciplinary, inclusive, decentral, networked, and non-linear. They seek to prevent, to be holistic and not specialist, to focus on cobenefits, and to emphasise front-line first (rather than top-down). Transformative coalitions are permanent beta and move dynamically with the change they make. Like GREENER, they do not intend to be perfect or orthodox. They set out for a transformational journey towards realising planetary health in all health and care education. We declare no competing interests.